Healthcare Provider Details

I. General information

NPI: 1114794252
Provider Name (Legal Business Name): JANICE HALLSTROM RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2023
Last Update Date: 12/08/2023
Certification Date: 12/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 N 9TH ST STE A
MODESTO CA
95350-5814
US

IV. Provider business mailing address

800 SCENIC DR
MODESTO CA
95350-6131
US

V. Phone/Fax

Practice location:
  • Phone: 209-525-5300
  • Fax:
Mailing address:
  • Phone: 209-525-5300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number780928
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: